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RD91  P93  1888       An  aseptic  atmospher 

1HBH  Prince. 

Palatoplasty. 


RECAP 


o 


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An  Aseptic  Atmosphere, 


CLUB   FOOT 


A  Rectal  Obturator. 


/PALATOPLASTY 


By  DAVID   PRINCE,  M.  D., 


JACKSONVILLE,  ILL. 


Jotirnal  Press. 

1888. 


WEBSTER  LIBSARV 

/Iff 

An  Attempt  to  Secure  a  Sterilized  Air 

FOR  SURROUNDING  THE  WOUND  AND  ENTERING  THE 
PERITONEAL  CAVITY  IN 

LAPAROTOMY, 

By  DAVID  PEiyCE,  M.  D., 

JACKSONVILLE,  ILL. 


The  extent  of  the  absorbing  surface  of  the  peritoneum,  makes  it  undesira- 
ble to  subject  it  to  .those  antiseptic  irrigations  which  are  found  to  be  so  bene- 
ficial in  other  wounds.  It  is  supposed  that  a  wound  made  in  the  amputation 
of  a  limb,  may  be  protected  from  the  injurious  contact  of  atmospheric  dust 
by  irrigation,  and  that  the  spray  of  carbolic  acid  diminishes  the  tendency  of 
ge^ms  to  develop  in  the  exudates.  The  skin  and  the  mucous  membranes  con- 
stitute a  barrier  to  the  entrance  of  floating  material  acting  as  a  poison  when 
it  gains  access  to  the  living  solids  and  fluids.  Some  of  these  atmospheric 
p  -ents  are  capable  of  entering  by  the  lungs,  without  a  previous  breach  of  sur- 
lace,  and  the  presence  or  absence  of  these  agents  in  the  air  (like  the  conta- 
gium  of  malarial  fever),  constitute  an  important  element  in  the  question  of 
the  healthfulness  of  a  dwelling  place.  Other  agents,  like  the  contagium  of 
erysipelas,  may  localize  themselves  in  a  habitation,  so  that  the  danger  of  in- 
fection continues  a  long  time  after  the  apparent  cause  has  been  removed. 

Until  within  a  few  years,  and  before  the  observations  with  which  the  name 
of  Joseph  Lister  is  indissolubly  associated,  the  infection  inhering  in  the  at- 
mosphere of  hospitals  was  a  mystery.  It  eluded  observation  and  investiga- 
tion. It  defied  every  attempt  at  removal  by  cleansing  and  the  replacing  of 
wall  paper  and  plastering;  in  short,  everything  except  the  complete  destruc- 
tion of  the  buildi'ng  itself.  The  difficulty  in  keeping  hospitals  free  from  in- 
fection, led  many  to  the  conviction  that  they  should  always  be  built  with 
reference  to  their  being  torn  down  after  a  temporary  use.  We  now  know 
that  the  prevention  of  such  inhering  infection  in  a  building,  is  the  avoidance 
of  the  first  case  of  disease,  or  such  management  of  it  by  antiseptic  agents,  as 
will  limit  the  production  of  the  contagium  to  the  smallest  possible  quantity, 
and  neutralize  that  which  is  unavoidably  produced.  By  antiseptics  and  ven- 
tilation, the  problem  as  to  house  infection  has  been  pretty  well  worked  out. 

The  problem  attempted  to  be  solved  in  this  paper,  is  to  secure  in  an  apart- 
ment for  any  convenient  length  of  time,  an  atmosphere  more  pure  than  the 
outdoor  air,  so  that  a  room,  or  any  number  of  them,  may  continue,  as  long  as 
the  machinery  is  in  operation,  to  contain  an  atmosphere  as  pure  as  that  of  a 
mountain  top. 

With  the  working  out  of  this  problem,  it  becomes  practicable  to  open  the 
abdomen  or  other  parts,  and  to  keep  it  open  an  hour  or  more,  and  on  closing 
it,  to  have  it  in  such  condition  as  to  material  floating  on  the  air,  as  it  would 
be  in,  if  all  the  proceedings  had  been  carried  on  subcutaneously. 

The  evidence  is  complete,  that  erysipelas  and  some  other  septic  infec- 
tions, are  capable  of  being  propagated  by  the  products  of  a  previous  disease 
of  the  same  kind. 

Prom  the  Transactions  of  the  9th  International  Medical  Congress,  Washington,  Sept.,  1887. 


The  experimental  evidence  by  inoculation  may  be  illustrated  by  a  quo- 
tation. 

In  the  "  Monograph  on  Micro-organism  and  Disease,"  by  Dr.  E.  Klein,  p. 
48  (McMillan  &  Co.,  1884),  Orth  is  quoted  as  having  cultivated  artificially 
the  micrococci  of  erysipelas,  and  afterward  reproduced  the  disease  in  rabbits 
by  inoculation.  Fehleisen  found  the  micrococci  only  in  the  lymphatics  of 
the  affected  parts,  and  those  he  cultivated  artificially  for  fourteen  genera- 
tions (which  it  took  two  months  to  do)  on  peptonized  meat  extract,  gelatine, 
and  solid  serum.  The  micrococci  form  a  whitish  film  on  the  top  of  the  nour- 
ishing material,  and  when  inoculated  into  the  ears  of  rabbits,  a  characteris- 
tic erysipelatous  rash  makes  its  appearance  after  from  thirty-six  to  forty- 
eight  hours,  and  spreads  to  the  roots  of  the  ears  and  further  on  to  the  head 
and  neck.  The  animals  do  not,  however,  die  from  it.  In  the  human  subject, 
he  produced  typical  erysipelas  after  inoculation  with  the  pure  cultured  mi- 
crococcus in  from  fifteen  to  sixty  hours.  These  inoculations  were  made  for 
the  purpose  of  curing  certain  tumors,  one  of  lupus,  one  of  cancer,  and  one 
of  sarcoma.  Fehleisen  also  in  several  instances  carried  out  a  second  inocu- 
lation successfully,  within  a  few  months.  He  found  that  a  three  per  cent, 
solution  of  carbolic  acid  and  a  one  per  cent,  solution  of  mercuric  bichloride 
destroyed  the  vitality  of  these  micrococci. 

That  the  material  is  also  capable  of  being  transmitted  through  the  air, 
and  of  fixing  itself  upon  wounds  or  abraded  places,  is  proved  by  the  strong- 
est possible  circumstantial  evidence.  This  being  admitted,  the  problem  of 
prevention  resolves  itself  into  that  of  exclusion  of  the  matter  from  contact 
with  the  susceptible  part,  or  destroying  it  between  the  moment  of  contact 
and  the  time  of  its  development  into  disease. 

The  spray  of  carbolic  acid  as  devised  by  Lister,  acts  probably  not  by  de- 
stroying the  septic  microbes,  nor  by  excluding  them,  but  by  rendering  the 
conditions  unfavorable  for  their  development.  The  spray  prevents  the  dry- 
ing of  the  exposed  wound  surfaces;  prevents  the  incipient  changes  which 
precede  apparent  decomposition,  at  the  same  time  that  the  germs  themselves 
are  depriv  d  of  the  surroundings  most  favorable  for  their  development.  In 
the  meantime,  the  germs  are  destroyed  by  the  white  blood  corpuscles  before 
they  have  developed  the  conditions  of  attack.  The  drip  or  douche  of  car- 
bolic acid,  or  of  mercuric  bichloride,  acts  in  the  same  way  to  wash  away  or 
to  neutralize  the  activity  of  such  germs  as  may  fall  upon  an  exposed  surface. 

While  this  may  be  said  of  ordinary  septic  germs,  it  is  not  so  certain  that 
pathogenic  germs,  like  those  of  erysipelas,  can  be  neutralized  by  the  action 
of  a  spray  or  a  douche,  if  they  are  once  implanted  upon  the  surface  of  the 
living  tissue. 

These  methods  are  liable  to  failure  in  cases  of  wounds  of  irregular  sur- 
faces, on  which  it  is  difficult  or  impossible  to  secure  an  adequate  application 
to  the  whole  surface,  of  sufficient  intensity  and  duration  to  destroy  the  in- 
vading virus.  The  exposure  having  been  made,  however,  the  chemical  or 
the  germicide  agent  is  the  only  thing  that  can  be  relied  upon  to  prevent  the 
natural  consequences.  The  perpetual  drip  of  a  weak  solution  of  carbolic 
acid  (one  per  cent,  solution)  has  been  proved  to  be  capable  of  preventing 
the  development  of  erysipelas,  and  of  putrefactive  changes  detrimental  to 
the  healthy  healing  of  wounds. 

, -     The  perpetual  bath,  antiseptically  medicated,  is  applicable  to  the  feet  and 

the  fore-arms,  and  by  tying  in  the  water,  it  is  applicable  to  the  whole  body, 
except  the  upper  part  of  the  neck  and  the  head.  Some  very  satisfactory  re- 
sults have  been  obtained  by  this  method  of  management. 

It  must  be  admitted,  however,  that  many  wounds  do  not  admit  of  the  pro- 
longed application  of  this  or  of  any  other  agent  capable  of  neutralizing  an 
infection  wThose  natural  development  is  that  of  erysipelas  or  of  putrefaction. 
Among  these  are  wounds  of  joints  and  of  the  peritoneal  and  the  pleural 
cavities  and  the  cavity  in  the  eye  cnntainingthe  acqueous  humor.  The  agents 
J  of  infection  once  introduced,  the  practitioner  is  at  great  disadvantage  in  the 
treatment  of  the  case. 


Much  may  be  done  by  drainage  and  the  introduction  of  disinfecting 
liquids,  but  it  is  necessary  that  they  shall  be  of  feeble  force,  in  order  not  to 
irritate  the  delicate  surfaces  or  not  to  poison  the  general  system  by  absorp- 
tion through  the  surfaces  to  which  they  are  applied.  It  follows  from  these 
considerations,  that  the  prevention  by  disinfecting  agents  should  be  the  least 
favored  method,  and  to  be  employed  where  the  prevention  by  exclusion  is 
impossible  or  has  been  neglected. 

The  exclusion  is  of  two  kinds:  the  immediate  and  temporary;  and  the 
permanent.  1st.  The  exclusion  of  those  agents  from  the  air  which  surrounds 
the  patient  at  the  time  of  an  operation,  by  means  capable  of  purifying  the 
whole  atmosphere  of  an  apartment,  or  the  portion  of  it  which  surrounds  the 
wound  in  the  progress  of  formation;  and  2d.  The  permanent  exclusion  of  an 
infected  atmosphere  by  the  mode  of  dressing. 

This  implies,  that  while  the  atmosphere  of  a  whole  room  may  be  made 
aseptic  during  the  time  in  which  an  operation  may  be  performed,  it  may  be 
too  troublesome  or  too  expensive  to  secure  a  perpetual  purification  of  the 
apartment  occupied  by  the  patient  during  his  recovery.  It  is  implied,  that 
the  exposed  wound  surface  may  be  effectually  secluded  from  contamination 
by  such  a  character  of  the  dressings  as  to  make  it  certain  that  the  infection 
will  be  arrested  or  destroyed. 

We  have  our  subject  classified  by  the  nature  of  things;  as 

1.  Antiseptic  applications  during  the  progress  of  cure. 

2.  The  arrest  of  the  access  of  infection  during  the  progress  of  cure  by 
the  -character  of  the  dressing  first  applied  and  allowed  to  remain. 

3.  The  purification  temporarily  of  the  air  of  an  apartment  in  which  a 
surgical  operation  may  be  performed. 

1st.  The  plan  of  the  first  method  is  that  of  a  perpetual  irrigation,  or  a 
perpetual  bath. 

2d.  The  second  plan  is  that  of  a  dressing  impervious  to  the  floating  ob- 
jects in  the  air,  and  it  includes  the  "Lister  dressing." 

It  is  found  that  it  is  of  no  advantage  to  have  the  dressing  air-tight  or 
water-tight,  but  that  a  material  with  fine  meshes,  like  that  of  cotton,  will 
answer  the  purpose.  If  the  wound  is  exposed  under  a  spray  or  douche,  and 
aseptic  cotton,  wool,  or  other  similar  material,  be  applied  and  retained,  the 
agents  of  septic  changes  cannot  enter  as  long  as  the  material  of  the  dressing 
is  entirely  dry.  It  is,  therefore,  convenient  to  have  the  cotton  or  other  sub- 
stance previously  treated  with  a  solution  of  mercuric  bichloride  or  other 
antiseptic,  the  water  being  dried  out  before  the  use  of  the  material  for  dress- 
ing. Otherwise  the  dressing,  infiltrated  with  the  exudations  from  the 
wound,  becomes  putrid,  requiring  its  removal  sooner  than  is  necessary  with  a 
dressing  capable  of  preserving  from  putrefaction  any  fluids  that  may  get 
into  it. 

In  applications  of  gypsum  it  is  convenient  to  wet  it  with  a  solution  of 
Hg.  CI  2. 

3d.  The  plan  of  the  third  class,  is  that  of  securing  the  freedom  of  a 
whole  apartment  from  floating  minute  particulate  material  of  all  kinds  dur- 
ing the  time  necessary  for  the  performance  of  a  surgical  operation,  or  the  ex- 
clusion of  air  dust  from  the  portion  of  air  surrounding  a  wound  and  entering 
into  it. 

It  is  exceedingly  probable,  that  if  the  cavity  of  the  peritoneum  or  any 
other  closed  cavity,  can  be  opened  in  an  atmosphere  free  from  floating  ma- 
terial, and  closed  again  after  a  short  period,  the  conditions  will  be  the  same 
as  though  the  work  of  removing  a  tumor,  or  other  operation,  had  been  done 
subcutaneously,  so  as  to  exclude  the  contact  of  air. 

The_  continued  purity  of  animal  and  vegetable  liquids  sterilized  and 
placed  in  vessels  closed  by  sterilized  cotton,  admitting  free  access  of  gases 
but  sifting  out  particulate  material,  affords  the  strongest  probability  to  the 
assumption  that  the  septic  changes  occurring  in  wounds  and  in  closed  cavi- 
ties into  which  air  has  entered,  would  not  occur,  if  the  air  were  free  from 
such  material  as  might  be  filtered  out  by  passing  through  cotton  or  other 


material  having  fine  meshes.  Reasoning  from  the  general  facts  here  referred 
to,  in  relation  to  animal  and  vegetable  fluids  secluded  from  the  floating  ma- 
terial of  the  air,  it  becomes  in  the  highest  degree  probable  that  the  material 
of  wounds  would  be  equally  exempt  from  change,  if  exempt  from  the  con- 
tact of  this  floating  material,  and  that  if  thus  secluded,  putrefactive  changes 
would  not  occur.  Wounds  and  injuries  which  are  subcutaneous,  show  an  ex- 
emption from  septic  changes,  though  a  great  amount  of  vascular  and  nervous 
disturbance  may  arise  from  the  injury. 

The  use  of  douches  and  irrigations,  is  not  for  the  purpose  of  purifying 
the  air,  but  for  washing  away  these  minute  particles,  or  rendering  them 
inert  by  some  influence  upon  them,  thus  rendering  them  less  able  to  germi- 
nate, or,  for  the  purpose  of  affecting  the  living  surfaces,  increasing  their  ca- 
pability of  resistance. 

I  visited  several  cities  of  Europe  in  the  summer  of  1884,  and  had  it  in 
mind  to  observe  what  provisions  were  made  toward  the  end  of  exemption 
from  septic  changes  incident  to  surgical  operations.  I  saw  several  new  rooms 
with  non-absorbable  floors,  walls  and  ceilings,  yet  having  doors  opening  into 
the  halls  of  hospitals.  There  were  provisions  for  non-absorption  of  anything 
floating  in  the  air  of  the  apartment,  but  no  provision  for  purifying  the  air. 

At  Hamburg,  in  connection  with  the  female  department  of  the  general 
hospital,  was  a  room  just  completed,  having  four  outside  walls,  so  that  it  was 
necessary  to  go  through  six  feet  of  open  air,  to  get  from  the  hospital  into  it. 
There  was  evidence  of  great  pains  to  secure  the  greatest  possible  degree  of 
cleanliness,  but  there  was  no  provision  for  a  better  air  than  the  outside  at- 
mosphere of  a  large  city.  I  came  home  resolved  to  do  something  better  than 
the  latest  improvement  in  Hamburg. 

The  apparatus  to  be  described  is  the  result  of  my  reflections  upon  the  sub- 
ject, and  experience  has  suggested  so  many  modifications  that  new  cuts  have 
been  necessary  in  order  to  illustrate  the  history  of  the  development  of  the 
idea,  and  the  adaptations  for  hot  and  for  cold  weather. 

For  hot  weather,  the  current  of  air  cannot  be  secured  by  heat  produced 
in  the  operating  room  above,  or  in  the  room  below,  but  must  be  obtained  by  a, 
draft  connected  with  a  chimney  operating  as  a  vis  a  f route  (which  is  practi- 
cable in  any  hospital  having  a  chimney  which  is  in  use  in  summer),or  by  a 
fan,  operating  as  a  vis  a  tergo,  blowing  air  into  the  basement,  which  is  to 
travel  upward  through  the  operating  room. 

Taking  a  hint  from  the  observations  recently  made  in  Paris  upon  the 
effect  of  rainy  weather  upon  the  number  of  microbes  floating  in  the  atmos- 
phere, it  occurred  to  ask,  whether  or  not  it  is  practicable  to  subject  the  air 
entering  an  operating  room  to  the  influence  of  artificial  showers  in  order  to 
precipitate  to  the  ground,  the  whole  or  greater  part  of  these  enemies  to 
surgery. 

They  are  known  to  be  heavier  than  the  air,  because  they  entirely  disap- 
pear from  the  air  within  a  tight  box  which  has  been  several  months  in  one 
position.  This  principle  of  rest  is  of  no  use  to  us,  for  the  purification  of  the 
air  of  an  operating  room  by  this  means  is  impracticable  The  commotion  of 
the  air  incident  to  the  use  of  a  room,  must  dislodge  the  minute  particles 
from  the  floors  and  walls,  and  set  them  floating  again  in  the  air,  besides  per- 
mitting the  entrance  of  common  air  from  without. 

The  dry  filtration  by  means  of  cotton  or  other  substances  to  entangle  and 
arrest  the  particulate  material  floating  in  the  air,  was  not  thought  practicable, 
on  account  of  the  rapidity  necessary  in  the  entrance  and  exit  of  the  air  in 
order  to  displace  the  agents  entering  from  without  during  the  progress  of  an 
operation,  and  also  those  emanating  from  the  occupants  of  the  room.  If, 
however,  we  can  cause  the  air  entering  the  room  to  pass  through  several 
showers  of  water,  we  have  an  expedient  which  may  entangle  these  objects  and 
carry  them  to  the  ground. 

This  paper  contains  five  illustrations  of  the  progress  of  thought  in  this 
direction. 

The  following  cut  illustrates  the  first  development  of  the  idea. 


5 

Fie.  1. 


A'~:\ 


. . — 

.     __.  : _J _ 

»a  isasasil 

1.    Basement. 

On  the  right  hand  is  an  entrance  ventilator  20  inches  in  diameter,  in  which  is  a  steam  jet 
for  the  purpose  of  infiltrating  the  entering  air  with  very  fine  globules  of  water.    (2)  (3). 

The  air  thus  moistened  passes  in  the  direction  of  the  arrows  under  a  screen  which  de- 
scends near  to  the  floor  (4).    It  is  then  warmed  by  a  stove  (5). 

The  air  then  passes  up  and  down' over  the  top  of  another  screen  and  up  through  a  series 
of  dripping  shelves  (li)  and  through  a  spray  (V)  into  the  operating  room  above. 

The  exit  ventilation  is  from  the  floor  through  the  shaft  (9)  communicating  with  an  open- 
ing in  the  roof.  Under  the  entering  flow  of  air  (3)  is  pot  (8)  for  burning  sulphur,  which  is  sup- 
posed to  combine  with  the  condensed  steam  and  form  a  disinfecting  solution  in  exceedingly 
fine  particles. 

It  has  been  found  that  the  smell  of  a  moderate  flame  of  sulphur  may  be  thus  entirely  sup- 
pressed so  as  not  to  be  perceived  in  the  room  above. 

This  cut  (Fig.  1)  was  first  published  in  the  St.  Louis  Medical  and  Surgical 
Journal  for  February,  1885;  afterward  in  the  American  practitionei  and 
News,  in  the  Transactions  of  the  American  Surgical  Association,  and  in  the 
Quarterly  Compend.  of  Medical  Science.  Fig.  2  shows  some  modification 
in  the  detail  of  the  same  plan.  [Continued  on  page  9.] 


Fi°\  2. 


Pig.  1.  Window  admitting  ontside  air. 

Fig.  2.  Steam  for  moistening  all  floating  particles. 

Fig.  3.  Sulphur  pot,  with  Bunsen  burner  under  it,  for  slow  combustion.  A  more  rapid 
combustion  is  secured  by  mixing  alcohol  with  the  sulphur. 

Fig.  4.  Spray  of  water  through  which  the  air  must  pass  in  going  to  the  next  apartment. 

Jng.  5.  Stove  for  heating  the  air  which  has  been  once  washed. 

Fig.  6.  Screen  for  forcing  the  air  to  pass  from  near  the  ceiling  through  the  next 
washer.  °  a 

•  FJ&- 1'    Snelves  of  thin  niuslin  through  which  water  drips  from  the  spray  in  the  opening 

in  the  floor  above.  f         s 

Fig.  9.    Entrance  of  the  air  of  the  room  into  the  draught  heated  to  hasten  the  rapidity  of 

tilO  ''SCJip©. 

Fig.  10.    Stationary  partition. 

Fig.  11.  Movable  portion  hinged  above,  and  taking  a  horizontal  position  under  VZ,  to 
close  the  exit  through  the  roof,  when  the  room  is  used  without  runnim*  the  ventillatin" 
svstem. 

Fig.  13.    Sky-light. 

The  third  figure  illustrates  the  advancement  of  the  idea  toward  the  cotton 


7 
Fig.  3. 


Scale,  One  to  Sixty. 
1.  Entrance  of  ontside  air  closed  when  the  pipe  (figure  2)  is  in  use. 
.     2.  Entrance  of  air  blown  in  by  a  fan  run  bv  an  engine  for  hot  weather.    Specific  gravity 
is  relied  upon  in  cold  weather  to  secure  atmospheric  motion  and  change. 

3.  Steam  Jet. 

4.  Sulphur  Flames. 

5.  Reservoir  for  Solution  of  Corrosive  Sublimate. 

6.  Screen  or  Partition  open  fifteen  inches  next  the  floor. 

7.  Spray  of  water  through  which  the  steamed  air  must  pass. 

8.  Box  for  flame  for  heating  water  as  it  runs  through  the  pipe. 
ft.  Stove. 

10.  Spray  of  Sublimate  water  for  the  second  washing  of  the  air  which  passes  through  18  17 

11.  Screen,  the  arrows  showing  the  course  of  the  air. 

12.  Series  of  muslin  shelves. 

13.  Spray  producing  the  shower  for  the  second  washing  of  the  air  going  to  the  room  above. 

14.  Stove  for  increasing  exit  draft. 

15.  Screen  separating  the  space  around  the  stove  from  the  general  air  of  the  room,  obliging 
the  escaping  air  to  go  from  the  floor.  B    B 

16.  Table. 

«'  VU-Pnpe  for  conveying  sterilized  air  to  the  region  of  a  surgical  operation. 
IS.  window.  D  ' 

19.  Skylight.    The  arrows  everywhere  show  the  course  of  the  air. 


Fig.  4 


c,  c,  c,  3  cotton  filters  for  inlet- 

cc,  cc,  cc,  3  cotton  filters  for  exit. 

da,  da,  da,  3  floors  under  the  inlet  filters. 

dd,  aa,  dd,  aa,  dd,  aa,  3  floors  under  the  outlet  filters. 


a,  Inlet  pipe. 

aa,  Outlet  pipe. 

6,  Ascending  inlet  pipe, 

66,  Descending  outlet  pipe. 

E,  Ascending  inlet  pipe. 
H,  Ascending  surgical  pipe. 

0,  Descending  surgical  pipe,  to  be  raised  or  lowered. 
K,  Thermometer. 

Under  g  and  over  gg  is  the  oblique  swr^'eaJ.branch  of  the  inlet  pipe. 
Gas,  Gas  flame  for  regulating  the  temperature  of  the  air  escaping  from  O. 
S,  Steam  jet  for  regulating  the  moisture  of  the  same  air. 
g,  At  tne  top  of  the  straight  pipe  g  is  an  eye  looking  at  the  flame  below 

curved  end  of  the  inlet  pipe  for  the  sanitary  use  of  purified  air. 
gg,  Over  gg  is  a  screen  to  interrupt  the  straight  horizontal  blow  of  the  same  air 
EE,  Descending  outlet  pipe. 

F,  Canopy. 

FF,  Canopy  let  down. 

L,  Surgical  table  in  section. 

M,  Sanitary  bed  in  section. 

The  important  objects  are  in  section. 


Above  g  is  the 


The  next  advance  in  the  conception  of  the  subject,  was  a  combination,  a 
purification  of  the  general  air  of  the  operating  room,  and  another  supply  of 
purified  air  to  envelop  a  wound  in  the  progress  of  its  formation. 

In  the  device  for  an  additional  and  separate  supply  of  air  for  the  wound 
itself,  a  difficulty  arose  in  the  conception  of  the  means  of  getting  it  there 
in  such  force  as  to  effectually  displace  the  other  air  of  the  room,  and  monopo- 
lize the  space  about  the  wound.  It  seemed  that  for  hot  weather  the  force  of 
a  fan  must  be  necessary. 

The  dry  filtration  by  means  of  cotton  or  other  substances  to  entangle  and 
arrest  the  particulate  material  floating  in  the  atmosphere  was  not  in  this 
stage  of  the  idea  thought  to  be  practicable  on  account  of  the  rapidity  neces- 
sary in  the  entrance  and  exit  of  air  in  sufficient  amount. 

It  is  intended  in  figure  4  to  illustrate  the  application  of  the  principle 
to  sanitary  as  well  as  to  surgical  purposes.  For  sanitary  ends  the  scheme 
illustrates  the  protection  of  a  person  from  the  evil  agents  in  general,  out- 
side of  a  room.  For  instance,  in  a  ship  passing  through  a  harbor  in  a 
locality  infected  with  yellow  fever  on  the  one  hand,  and  on  the  other  hand 
the  protection  of  persons  outside  from  the  infection  of  a  yellow  fever  patient 
brought  into  a  previously  uninfected  district. 

On  ship  board,  the  ventilation  is  supposed  to  be  secured  by  a  fan  run  by 
the  steam  apparatus ;  on  land  some  power  most  convenient. 

The  plan  of  filtration  through  cotton  is  illustrated  in  Fig.  4,  for  surgical 
and  sanitary  purposes,  and  in  Fig.  5,  for  surgical  purposes  alone. 

The  room  in  which  this  scheme  has  been  worked  out  for  surgical  pur- 
poses, has  a  capacity  of  3,360  cubic  feet. 

The  air  is  taken  from  outside  the  building  and  carried  through  nine 
hundred  and  sixty  square  inches  of  cotton  an  inch  thick  by  means  of  a  fan  or 
blower  which  theoretically  should  change  the  whole  air  of  the  room  once  in 
five  minutes.  Any  object  exposed  under  the  tube  is.  shielded  from  the  con- 
tact of  the  general  air  of  the  room. 

The  blower  (No.  00  of  the  Sturtevant  manufacture)  revolves  3,512  times  in 
a  minute.  This  is  a  rate  of  speed  which  makes  very  little  noise  and  is  suffi- 
cient for  the  purpose.  At  this  rate  of  speed,  it  is  estimated  by  the  manufac- 
turer, to  carry  662  cubic  feet  of  air  in  one  minute.  This  rate  of  air  supply 
would  completely  change  the  air  of  the  room  in  five  minutes. 

There  are,  however,  three  elements  of  loss,  viz:  the  slipping  of  the  band, 
the  escape  by  leakage  through  a  long  pipe,  and  the  resisting  influence  of 
friction  by  which  the  fans  of  the  blower  slip  on  the  air  which  they  propel. 
It  may  be  assumed  that  this  loss  amounts  to  one-half.  The  air  of  the  room 
would  then  be  completely  changed  once  in  ten  minutes. 

The  fifth  figure  illustrates  the  application  of  the  principle  to  surgical 
purposes  alone,  and  has  been  executed  especially  for  use  in  this  presentation 
of  the  subject. 

A  sufficient  number  of  observations  have  been  made  upon  substances  capa- 
able  of  decomposition,  to  show  a  great  superiority  in  the  freedom  of  this  cot- 
ton filtered  air  over  the  air  of  the  same  room  and  over  the  air  of  out  doors  and 
also  of  that  in  other  parts  of  the  house.  It  is  certain,  therefore,  that  the  en- 
deavor has  been  successful,  to  the  extent  of  securing  for  surgical  purposes,  an 
atmosphere  far  superior  to  that  of  the  open  out  door  air.  By  this  apparatus, 
it  is  practicable  to  make  a  laparotomy  in  an  amphitheater  filled  with  specta- 
tors, any  number  of  whom  may  have  just  come  from  dissecting  rooms  and 
wards  having  erysipelatous  patients,  while  the  air  enveloping  the  wound  in 
progress  of  being  made,  shall  be  as  pure  as  that  of  a  snow  covered  mountain. 
An  observation  commencing  June  22,  1887,  by  Dr.  Grant  Cullimore,  in 
which  nine  tubes  containing  sterilized  peptonized  beef  broth  were  exposed 
(1)  under  the  blower,  supplying  air  which  had  passed  through  the  cotton  fil- 
ter, seventeen  minutes. 

On  the  same  day  and  under  the  same  circumstances,  nine  tubes  were  ex- 
posed seventeen  minutes  in  each  of  three  other  rooms  numbered  (2),  (3),  (4). 
No.  2  (cottage)  is  in  a  detached  building  of  two  rooms,  unoccupied  for  several 


11 

months.  No.  3  (upper  floor)  has  been  unoccupied  several  weeks,  but  some 
months  before  had  in  it,  erysipelas,  gangrene  and  diphtheria.  Room  No.  4  is 
a  dissecting  room  one  month  after  its  use ;  the  air  being  still  from  the  close- 
ure  of  door  and  window.  The  tubes,  after  exposure  and  sealing  with  cotton, 
were  kept  in  an  incubator  with  a  uniform  temperature  of  100°  F. 

Other  observations  employing  liquids  and  also  potato  slices,  have  shown 
a  great  superiority  of  the  purity  of  the  air  thus  filtered,  over  that  of  the  open 
air  and  that  of  rooms  whether  empty  or  occupied. 

The  observation  of  Dr.  Grant  Cullimore  is  sufficient  to  publish  in  detail 
as  an  illustration: 

23d.    (1)    The  tubes  exposed  to  cotton  filtered  air  all  remained  clear. 

24th.     Same  condition. 

25th,  26th,  27th.     No  observation. 

28th.  Each  of  the  nine  tubes  held  up  by  the  side  of  No.  9  of  series  (4) 
shows  a  cleanness  in  great  contrast.  This  tube  of  the  fourth  series  was 
slightly  turbid  and  under  the  microscope  showed  the  bacillis  subtilis. 

(2)  This  room  (cottage)  has  been  unoccupied  several  months,  but  the  win- 
dows have  been  left  open. 

23d.  (2)  Two  tubes  (Nos.  3  and  8)  are  turbid,  showing  long  bacilli  with 
spore  formation. 

24th.     Same  condition. 

25th,  26th,  27th.     No  examination. 

28th.  Tube  No.  2  shows  a  small  deposit  at  the  bottom,  clear  in  the  mid- 
dle portion.  At  the  top  a  film  hangs  together  and  is  not  easily  separated — of 
a  dirty  brown  color  on  top  and  white  below.  Among  other  microbes  is  that 
of  the  yeast  plant.     Tubes  numbered  1,  4  and  9  remain  clear. 

June  22d.  (3)  Nine  tubes  exposed  seventeen  minutes  in  room  (3),  upper 
floor. 

23d.  Pour  tubes,  1,  2,  3  and  5,  are  turbid.  Two  with  vibratile  bacilli  of 
medium  length ;  one  shows  rods  without  motion,  and  one  a  film  which  shows 
microscopic  bodies  like  crystals  of  cerium  oxalate. 

24th.     Same  condition. 

25th,  26th,  27th.     No  observation. 

28th.  Tubes  Nos.  1,  4,  6,  7  and  9  clear.  Tube  No.  2  shows  mycelium, 
bacilli  and  spores. 

(4)    Dissecting  room. 

June  22d.    Nine  tubes  were  exposed  seventeen  minutes. 

23d.  Two  tubes,  Nos.  6  and  8,  have  a  thin  pellicle  at  the  top,  easily  broken 
up.  The  microscopic  appearance  is  like  that  of  mycelium.  Tube  No.  5 
showed  bacillis  subtilis ;  8  and  9  turbid. 

24th.    Same  condition. 

28th.  Tubes  Nos.  1,  2,  3, 4  and  7  remai>n  clear.  Tube  No.  9  showed  slight 
turbidity  from  commencing  development  of  micrococcus  and  was  used  for 
comparison  with  the  tubes  of  the  first  series  expesed  to  sterilized  air. 

The  good  behavior  of  the  air  of  this  dissecting  room  is  accounted  for  by 
its  stillness  and  the  opportunity  for  its  dust  to  settle. 

Fig.  5. 

a,  b.    Entering  pipe  seven  inches  in  diameter. 

c,  c,  c.  Three  cotton  filters  forty  inches  square,  the  cotton  being  an  inch  thick,  over 
■which  the  air  enters  as  indicated  by  the  arrows.  There  is  another  set  of  filters  in  another 
bos,  making  9,600  square  inches  of  cotton  through  which  the  air  passes. 

a  a,  d  a,  d  a.    Spaces  from  which  the  filtered  air  escapes. 

E.    Exit  pipe  collecting  the  filtered  air  from  under  the  filters. 

Gas.    Gas  jets  for  warming  the  air. 

S.    Steam  spray  for  moisture. 

g.    Straight  pipe  for  observation. 

gg.    Oblique  portion. 

H.    Vertical  portion. 

O.    A  sliding  portion  to  resrulate  the  height  of  the  exit. 

K.    Thermometer. 

L.    Operating  table. 


The  question  of  microbic  influence  upon  the  results  of  wounds  of  closed 
cavities,  is  further  illustrated  by  a  statement  made  before  the  French  Sur- 
gical Congress  meeting  in  Paris,  in  April,  1885,  {Revue  de  Chirurgie,  March, 
1885,  page  359,)  by  M.  Abadie  of  Paris.  In  the  course  of  extended  remarks 
upon  this  subject,  are  the  following  paragraphs : 

"A  factor  of  the  greatest  importance  is  the  microbic  element.  I  can  easily 
demonstrate  this  by  taking  the  experience  of  ophthalmic  surgeons,  when, 
after  an  operation  for  cataract,  there  appears  suppuration  in  the  eye.  This 
complication  should  not  be  attributed  to  some  influence  of  diathesis,  but  to 
some  infecting  cause.    The  essential  condition  is  local  and  external. 

"Previously  to  antiseptic  practices,  it  was  remarked,  that  suppuration  did 
not  occur  after  iridectomy,  though  a  frequent  accident  after  cataract  extrac- 
tion. The  reason  is,  that  after  the  operation  for  cataract,  the  aqueous  humor 
is  modified  so  as  to  contain  more  albuminoid  material,  becoming  a  better 
medium  for  culture,  and  of  the  multiplication  of  the  micro-organisms  of 
suppuration. 

"At  this  time,  I  think  that  sufficient  care  is  taken  of  one's  person,  of  those 
of  assistants,  and  of  instruments,  but  the  atmospheric  medium  of  the  opera- 
tion is  neglected.  The  best  protective  dressings  are  applied  too  late,  if  the 
inoculation  has  already  been  made. 

"The  air  in  which  we  live  is  surcharged  with  microbes  in  innumerable 
quantities,  which  hasten  putrefaction  and  interfere  with  the  regular  devel- 
opment of  cicatrization." 

This  is  an  extravagant  estimate  of  the  exclusive  evil  influence  of  the  air 
dust  entering  the  eye,  because  we  know  that  eyes  are  lost  from  injuries  in 
which  the  external  membranes  are  not  ruptured  and  from  diseases  which 
arise  spontaneously.  An  operation  made,  however  aseptically,  upon  an  eye 
about  to  go  into  destructive  degeneration,  must  terminate  disastrously. 

There  is  no  doubt,  however,  that  most  of  the  eyes  that  are  lost  after  opera- 
tions, might  have  been  saved  by  the  avoidance  of  the  entrance  of  floating 
atmospheric  particulate  material. 

The  following  statistics  are  interesting  in  this  connection: 

Dr.  Arthur  E.  Prince  has  made  cataract  extractions  on  thirty-five  eyes  in 
this  room  since  its  opening  in  November,  1884,  without  a  case  of  corneal 
ulceration  among  them.  In  each  case  an  ointment  of  iodoform,  two  parts  in 
a  hundred  of  vaseline,  was  introduced  into  the  conjunctional  duplicatures 
before  the  application  of  the  bandage. 

Of  a  series  of  sixteen  cases  performed  successively  in  the  patients'  homes, 
or  in  other  rooms  in  this  private  hospital,  the  first  and  the  last  eyes  were  lost 
through  corneal  destruction.  In  the  last  patient  belonging  to  this  list,  a  lady 
85  years  old,  one  eye  did  well  and  the  other  went  into  destructive  inflamma- 
tion, resulting  in  pain,  high  temperature  and  delirium,  terminating  in  death. 
The  two  lists  added  make  fifty-one,  of  which  forty-nine  in  succession  were 
successful. 

The  elimination  from  the  estimate  of  dangers  in  laparotomy,  of  that  of 
septic  contamination,  has  been  accomplished  by  the  employment  of  this  ap- 
paratus to  such  an  extent,  as  nearly  to  place  it  outside  of  the  estimated  fac- 
tors of  danger  in  a  contemplated  case. 

The  necessity  remains  for  attention  to  the  fingers,  the  instruments,  the 
sponges  or  napkins,  to  drainage  and  the  mode  of  dressing,  but  it  is  not  in  the 
plan  of  this  presentation  to  go  into  these  questions. 

It  is  not  assumed  that  the  technology  of  laparotomy  is  finished,  by  having 
a  sterilized  air  for  the  envelopment  of  a  wound  in  the  progress  of  formation. 
The  danger  of  shock,  hemorrhage,  obstruction  of  the  bowels  from  inflam 
matory  adhesions,  and  from  the  subsequent  entrance  of  putrefactive  and  other 
infections,  remains  the  same  as  before. 

There  is  a  question  not  often  taken  into  consideration;  that  is,  the  extpnt 
to  which  a  wound  may  be  poisoned  by  the  dust  of  a  surgeon's  hair  and  the 
breath  of  himself  and  his  assistants. 

In  the  position  of  one's  head  over  a  wound,  it  may  be  an  easy  fortuity  for 


13 

dust  and  sweat  to  fall  in,  and  the  dust  from  hair  and  head  may  be  wafted 
laterally  by  currents  of  air  until  they  fall  into  the  wound  under  treatment. 

The  breath  of  surgeons  and  assistants  unavoidably  enters  a  wound  under 
ordinary  circumstances.  It  mingles  with  other  air  and  enters  an  open  peri 
toneal  cavity.  In  a  perfect  state  of  health  it  may  be  better  than  other  sur- 
rounding air,  in  consequence  of  leaving  some  of  the  floating  particles  along 
the  moist  air  passages.  In  case,  however,  of  diseased  surfaces,  from  mouth 
and  nose  to  lungs,  it  is  easily  conceived  that  particulate  material  from  these 
surfaces,  including  the  germs  of  suppuration  and  septic  development,  may 
be  the  true  cause  of  complications  not  otherwise  explained. 

Some  observations  upon  the  particulate  contents  of  the  expired  air  have 
been  made  by  Shablovsky  and  Vargunin  of  St.  Petersburg,  Russia,  Some 
account  of  these  appeared  in  the  Philadelphia  Medical  News  for  November 
24,  1887,  from  the  Medical  Chronicle  for  November,  1887. 

According  to  these  observations,  the  average  number  of  microbes  in  the 
expired  air  (those  of  the  surrounding  air  being  taken  at  100  per  cent.)  amounts 
to  54.18  per  cent.  According  to  this,  45.72  per  cent,  are  lost  in  the  air  pas- 
sages; and  if  these  passages  are  healtby,  the  expired  air  ought  to  be  purer 
than  the  surrounding  air. 

The  first  half  of  the  expired  air  has  twice  as  many  microbes  as  the  last 
half,  showing  that  the  air  that  has  remained  longest  in  the  lungs  has  lost  the 
most.  The  microbes  found  in  the  expired  air  were  found  to  be  mould  fungus, 
yeast  fungus  and  the  bacillus  subtilis,  with  a  large  number  not  differentiated 
and  named.  The  danger  therefore  is  not  in  the  microbes  that  have  been 
returned  to  the  surrounding  air,  but  in  those  that  have  originated  from  dis- 
eased surfaces.  The  apparatus  here  described  prevents  the  possibility  of  in- 
fection from  these  causes,  by  blowing  away  all  air  not  in  its  own  current,  and 
monopolizing  the  field  by  its  own  cotton  filtered  air.  It  is  a  satisfaction  to 
know  what  kind  of  air  enters  a  wound,  and  in  searching  for  causes  of  suppura- 
tion and  septiccom plications;  to  be  able  to  eliminate  the  atmospheric  element. 

Fingers  and  instruments,  with  the  possible  approach  through  the  blood  of 
the  patient,  remain  for  consideration.  The  razor  for-  the  hair  of  the  hands 
and  arms;  soap  and  nail  scrapers,  must  receive  proper  attention  at  the  same 
time  that  the  therapeutic  fortification  of  the  patient  against  suppurative  dis- 
eases is  attended  to.  The  surgeon  treats  his  patient  internally  with  iron, 
quinine  and  laxatives,  and  treats  his  hands  and  his  instruments  externally, 
trusting  that  the  dust  he  raises  will  be  blown  away  and  replaced  by  the  pure 
air  of  the  blower.  The  endeavor  is  to  make  all  wounds  behave  as  well  as  the 
best;  to  aid  the  forces  of  Nature  by  lessening  the  number  of  her  enemies, 
thus  securing  a  sense  of  safety  in  the  management  of  the  class  of  wounds  in 
which  septic  complications  le"ad  to  death. 

Drainage  is  a  good  or  an  evil,  according  to  its  management,  whether  or 
not  it  lets  out  more  enemies  than  it  lets  in.  A  mere  drainage  is  not  thorough 
enough.  Septic  microbes  will  travel  up  the  sluggish  stream  of  a  drainage 
tube.  The  tube  must  be  flushed  often  enough  to  remove  or  destroy  the  germs 
which  enter  from  the  air.  Theoretically,  a  cotton  plug  ought  to  be  a  sufficient 
protection,  but  the  management  is  not  likely  to  be  perfect. 

A  flushing  once  in  three  hours,  with  a  sublimate  solution,  Cone  to  ten 
thousand,)  with  a  cotton  plug  in  the  drainage  tube  during  the  intermediate 
time,  constitutes  the  best  protection.  The  sooner,  after  the  exudation  or  effu- 
sion of  fluids  from  serous  or  wound  surfaces,  it  is  removed,  the  greater  the 
chances  will  be  for  organization  of  the  solid  remains:  the  completion  of  repairs. 

Immediately  after  a  laparotomy,  the  fluids  seek  the  lowest  places  accord- 
ing to  gravity,  but  if  these  lowest  places  are  occupied  with  fluid,  the  surfaces 
or  higher  places  will  become  the  seats  of  fluid  accumulations,  and  these 
higher  accumulations  may  be  cut  off  from  their  descent  by  adhesions.  Then, 
when  the  lower  accumulations  are  drawn  off,  the  higher  ones  remain  as  ab- 
scesses or  the  centers  of  putrefactive  disseminations. 

The  word  drainage  is  therefere  misleading.  The  idea  of  draining  should 
be  supplemented  by  the  idea  of  flushing. 

A  weak  solution  of  boric  acid  or  of  boroglyceride  may  be  considered  safe 
as  an  immediate  flushing  in  relation  to  constitutional  injury  from  absorbtion 
over  large  extents  of  peritoneal  membrane. 

The  good  behavior  of  wounds  included  in  laparotomy,  is  usually  assured 
in  three  days,  while  slow  septic  complications  often  manifest  themselves  at 
later  periods,  the  infection  being  slow  at  first,  but  afterwards  rapid.  This 
direction  of  thought  leads  to  the  plan  of  preventive  drainage  combined  with 
protective  flmhaqe. 


CLUB   FOOT. 


[Reprinted  from  the  St.  Louis  Medical  and  Surgical  Journal  for  May,  1888.] 

It  will  be  borne  in  mind,  that  in  most  cases  there  is  a  doubling  of  the 
foot  at  the  waist,  or  at  the  joining  of  the  calcaneum  with  the  cuboid 
bone  on  the  outside  of  the  foot,  and  of  the  astragulus  with  the  scap- 
hoid, and  through  this  medium  with  the  cuneiform  bones  on  the  upper 
and  inside.  This  arching  of  the  instep  becomes  firm  by  means  of  short- 
ening of  the  ligaments  on  the  plantar  surface,  by  which  these  bones  are 
held  together. 

(Fig.  1  illustrates  this  condition.) 
They  are  entirely  beyond  the  reach  of 
any  cutting  instrument,  unless  an  open 
dissection  is  made,  and  they  are  too 
strong  to  be  torn  by  any  sudden  force 
which  can  be  applied  by  the  hand. 

The  indication  is  to  apply  force  to 
the  plantar  surface  of  the  metatarsal 
bones.  The  tibia  is  the  fulcrum  of 
this  lever  and  the  shortened  tendo- 
achillis  is  the  resistance. 

As  one  of  the  objects  to  be  accom- 
plished is  the  straightening  of  the 
crooked  lever  (the  foot  being  the 
lever)  it  is  important  that  there  should  , 
be  a  pretty  firm  resistance  at  the  heel. ' 
Any  diminution  of  the  force  with  ' 
which  the  tendo-Achillis  resists  the 
pressure  upon  the  metatarsus,  by  so 
far  diminishes  the  only  means  by 
which  the  surgeon  accomplishes  the  straightening  of  the  foot.  The  di- 
vision of  the  tendo  Achillis  is  therefore  worse  than  useless,  unless  there 
is  an  absence  of  the  usual  curvature  at  the  waist  of  the  foot,  The  high 
instep  which  is  often  seen  after  the  treatment  of  Talipes-equinius  by 
division  of  this  tendon,  is  thus  accounted  for.  Hereafter,  with  the  gen- 
eral abandonment  of  this  treatment  by  tenotomy,  a  more  natural  shape 
of  the  instep  will  be  secured  by  the  time  the  heel  is  brought  down.  We 
are  now  ready  to  appreciate  the  principle  which  should  control  the  con- 
struction of  apparatus.     It  is  simply  that  of  a  lever. 

Fig.  2  represents  one  of  the  forms  which  the  lever  may  be  made 
to  assume   in    the  treatment    of    Talipes  equinus.      While   the    appa- 


Fig.  1.    From  Little, 


15 

ratus  is  attached  to  the  sole  of  a  shoe  so  as  to  bring  the  pressure  under 
the  metatarsal  bones,  a  strap  passes  over  the  waist  of  the  foot  which 
throws  the  upper  end  of  the  apparatus  forward  of  the  leg.  This  upper 
end  is  thus  drawn  back  by  means  of  a  strap  passing  behind  the  leg. 

Fig.  2.  A  very  powerful  traction  upon 
the  tendo  Achillis  is  thus  obtained  with- 
out interfering  with  the  locomotion  of 
the  patient.  Indeed,  the  motion  incident  to 
walking  is  an  advantage,  as  the  ligaments 
and  tendons  yield  more  readily  to  a  tension 
which  is  constantly  varying  than  to  a  steady 
pull.  The  reason  of  this  is,  that  a  much 
greater  tension  can  be  endured  for  the 
moment,  followed  by  partial  or  complete 
Fig.  2.  rest,  than  where  it  is  continuous. 

a.    The  sole  of  a  shoe.    The  tipper  part  to  be  imagined. 

66.    A  flat,  thin  plate  of  iron  attached  to  the  sole.    The  turned  np  ends  of  this  plate 
are  perforated  for  a  joint. 

cc.    The  angle  of  a  metallic  strap,  the  horizontal  part  of  which  is  parallel  with  the 
sole  and  the  vertical  part  with  the  leg. 

dd.    The  vertical  portion  of  the  strap.    This  is  a  lever  with  fulcrum  at  c.    The  resist- 
ance at  6,  while  the  power  is  applied  around  the  leg. 

c.  The  metallic  bow  which  connects  the  two  parallel  levers  at  the  top.  A  leather 
strap  passes  across  the  instep  and  has  its  attachment  at  cc. 

The  cut  (Fig..2j  represents  an  easy  method  of  meeting  the  mechanical 
indication  which  has  just  been  considered.  It  is  the  skeleton  only  of 
an  apparatus.  Xeither  the  leather  fastenings  nor  the  enclosed  foot  are 
shown.     The  imagination  can  see  them. 

The  treatment  of  talipes  varus,  without  the  use  of  any  cutting  instru- 
ment, is  practicable  in  almost  all  cases,  if  undertaken  before  the  period 
of  walking. 

The  parts  are  yielding  and  the  metamorphosis  of  tissue  is  very  rapid. 
The  new  growth  in  the  progress  of  treatment  is  in  the  forced  direction, 
in  verifaction  of  the  maxim:  "As  the  twig  is  bent  the  tree  is  inclined." 
It  is  a  question  of  time,  and  as  soon  as  the  progress  is  at  such  a  stage 
that  the  act  of  walking  comes  in  the  ordinary  development  of  growth, 
the  exercise  of  the  natural  function  of  the  organ  tends  to  confirm  and 
complete  the  restoration. 

If  one  with  his  hands,  takes  hold  of  a  foot  congenitally  deformed, 
while  the  foot  is  yielding,  as  it  is  before  it  becomes  stiffened  in  walking, 
he  can  go  a  great  way  toward  restoring  the  foot  to  its  natural  form.  The 
problem  is  to  adapt  appliances  to  imitate  the  action  of  the  hand; — some- 
thing that  will  not  get  tired,  but  will  tire  out  the  elastic  resistance  of  the 
muscles,  the  tendons  and  the  connective  tissue. 

No  satisfactory  shoe  has  yet  been  contrived.  It  is  to  be  remembered 
that  the  parts  will  not  endure  long  continued  pressure,  and  a  shoe  will 
press  every  day  on  the  same  place. 

A  person  confined  to  the  same  position  while  undergoing  treatment 
for  fracture  of  a  bone  without  careful  attention  to  the  necessary  changes 
of  places  of  greatest  pressure  upon  the  surface,  gets  a  bed  sore. 

The  deformed  foot  confined  in  a  shoe  which  is  made  to  press  every 


16 

day  upon  the  same  part,  with  sufficient  force  to  alter  its  shape,  is  under 
the  same  necessity  for  a  change  in  the  places  of  the  greatest  pressure; 
otherwise  there  comes  a  sore  corresponding  with  a  bed  sore. 

The  pressure  can  be  intermitted  by  the  temporary  removal  of  the 
shoe,  but  on  re-applying  it,  the  pressure  comes  back  upon  the  same  sur- 
faces. On  the  other  hand,  some  extemporised  appliance,  which  is  not 
removed  and  reapplied  as  a  whole,  but  in  parts,  making  its  greatest  pres- 
sure in  a  little  different  place  with  each  application,  gives  the  parts  sub- 
jected to  the  greatest  pressure  one  day,  an  opportunity  to  rest  the  next,  on 
the  change  of  the  dressing  and  the  consequent  variation  of  pressure. 
In  talipes  varus  and  equino-varus  there  are  two  principal .  points  to  be 
approximated.  Some  point  on  the  outer,  or  outer  and  front  of  the  leg 
jnst  below  the  knee,  and  the  other  point  upon  the  outer  surface  of  the 
foot  over  the  metatarsal  bone  of  the  little  toe.  This  is  ordinarily  most 
easily  accomplished  by  binding  to  the  leig  by  means  of  strips  of  adhe- 
sive plaster  a  piece  of  tin  having  two  hooks.  There  should  be  (Fig.  3) 
more  than  one  hook,  in  order  to  vary  the  point  of  application  without 
the  removal  of  the  tin.  For  the  application  to  the  foot,  the  best  plan  is 
to  bind  to  the  sole  of  the  foot  some  light  shield  of  leather,  gutta  percha 
or  tin,  in  order  to  distribute  the  pressure  and  avoid  uncomfortable  pres- 
sure on  a  small  surface.  This  shield  of  tin  or  other  substance 
should  have  an  eye  or  ear  situated  on  the  outside  of  the  metatarsal  bone 
of  the  little  toe,  for  the  attachment  of  a  cord  which  is  to  extend  to  one 
of  the  hooks  on  the  tin  shield  attached  to  the  leg.  In  this  cord,  acting 
as  an  extending  brace  between  the  distal  part  of  the  tarsus  end  the  prox- 
imal part  of  the  leg,  there  should  be  intercollated  some  elastic  material 
in  order  to  secure  a  perpetual  moderate  extension.  (See  Fig.  3.)  The 
apparatus  illustrated  in  Fig.  2  is  applicable  to  Talipes  equinus  or  to 
Talipes  varus,  after  the  deformity  has  been  nearly  or  quite  removed.  For 
Talipes  equino-varus,  constituting  the  greater  portion  of  the  cases  of 
congenital  club  foot,  it  is  necessary  to  have  some  appliance  which  shall 
roll  the  foot  at  the  same  time  that  the  heel  is  brought  down.  The 
places  of  pressure  with  each  removal  and  replacement  of  dressing  will 
be  a  little  different,  so  that  pa»-ts  pressed  too  much  one  day,  will  be 
pressed  a  little  less  the  next. 

The  tin  under  the  sole  of  the  foot  is  seen  to  be  held 
b}r  stripe  of  plaster. 

The  tin  upon  the  outer  side  of  the  leg  is  seen  to  be 
held  in  the  same  way. 

The  elastic  cord  approximates  the  outer  part  of  the 
foot  toward  the  outer  part  of  the  leg,  performing  the 
functions  of  the  peroneus  longus  and  the  peroneus 
tertius. 

Any  apparatus  which  acts  like  the  hand 
renders  unnecessary  the  division  of  any 
other  tendon  than  that  of  the  heel. 

The   most  yielding  parts  soon  elongate, 

Fig.  3.  so  that  the  whole    force    comes   upon  the 

parts  more  unyielding — chiefly  the    short  ligaments    which  bind  the 

bones  of    the    tarsus  and    those   of    the    ankle  together.      It    greatly 


17 


hastens  the  progress  of  cure  to  give  the  little  patient  ether,  and  with  the 
hand  of  the  operator  to  rupture  these  most  resisting  ligaments  and  con- 
densed layers  of  bundles  of  connective  tissue.  Then,  in  a  few  days,  a 
point  of  no  progress  will  again  be  seem  to  have  been  reached,  when 
another  etherization  should  be  practiced  and  another  set  of  resisting 
parts  ruptured  by  the  force  of  hand.  The  resisting  parts  will  usually 
tear  with  a  vibration  felt  by  the  hand,  with  a  cracking  sound.  A  very  small 
amount  of  irritation  follows  this  apparently  harsh  treatment,  if  only  the 
foot  is  kept  for  a  time  immovable,  by  dressings  that  do  not  produce  tension 
of  any  part.  This  first  dressing  after  this  stretching  should  not  be 
elastic.  It  should  be  easy,  but  immovable,  for  a  day  or  two,  when  the 
elastic  tension  may  again  be  resorted  to,  but  it  should  never  be  to  such  a 
degree  as  to  be  uncomfortable. 

There  is  hardly  any  deformity,  unless  attended  by  active  spastic  or 
irritative  contraction,  having  its  origin  in  the  central  nervous  system, 
which  cannot  be  changed  slowly  by  the  careful  application  of  moderate 
force  during  a  sufficiently  long  period. 

The  progress  of  the  treatment  on  this  plan  undertaken  after  the  be- 
ginning of  the  period  of  walking  is  ordinarily  so  slow  that  it  is  more 
satisfactory  to  take  out  a  triangular  portion  of  the  tarsus,  unless  the  cir- 
cumstances are  such  that  prolonged  time  and  attention  are  not  attended 
with  great  inconvenience. 

The  following  four  cuts  illustrate  appliances  and  results  worked  out 
several  years  ago;  gutta  percha  being  the  agent  employed.  It  was  ap- 
plied in  the  warm  state  and  allowed  to  cool  under  the  pressure  of  a  pair 
df  calipers. 


Fig.  5. 


Fig.  6. 


18 


Fig. 


Fig.  8. 
Fig.  8  ilustrates  a  form  of  brace  intended 
to  counteract  the  moderate  tendency  of  the 
foot  to  turn  over.     It  is   rather   preventive 
of  deformity  than  cunative. 

TARSECTOMY. 


A.mong  the  fruits  of  modern  ideas  in  relation  to  the  antiseptic  treat- 
ment of  wounds,  is  that  of  daring  to  cut  into  the  cavities  of  joints  with- 
out fear  of  septic  troubles. 

Progress  in  the  methods  of  treatment  of  talipes,  in  persons  beyond 
the  period  of  infancy,  has  been  retarded  by  the  fear  of  septic  decompo- 
sition of  the  fluids  in  the  complicated  joints  of  the  tarsus  with  septic 
absorption  and  consequent  poisoning  of  the  general  system,  endangering 
the  life  of  the  patient. 

Ablation  of  the  cuboid  bone  in  the  treatment  of  club  foot  is  supposed 
to  have  been  first  suggested  by  Little  in  his  work  entitled  "Deformities 
of  the  Human  Frame,"  p.  305.     London,  1853. 

This  suggestion  was  put  into  practice  without  a  satisfactory  result,  by 
S.  Solly  in  1854. 

Mr.  Lund,  of  Manchester,  remored  the  astragalus  in  the  treatment  of 
club  foot  in  1872.     (1.) 

Resection  of  a  wedge  shaped  portion  of  the  tarsus  is  said  to  have 
been  first  performed  by  Mr.  Davies-Colley  in  October,  1875,  and  repeated 
by  Richard  Davey  in  November,  1876.     (2.) 

In  a  discussion  in  the  Copenhagen  Congress,  Ruprecht,  of  Dresden' 
denominated  the  removal  of  a  wedge-shaped  portion  of  the  tarsus.  Tarso- 
tomie  de  Poinsot. 

In  a  letter  dated  January  31,1888,  Mr.  Richard  Davey  reported  forty- 
one  cases  of  operation  by  himself,  according  to  this  method,  with  forty 
cases  of  success  and  one  death  from  septicaemia.     Mr.  Davey  employs  no 


Proceedings  Medical  Society  of  London,  Vol.  IV.,  1879. 
(2.)    Ibid. 


19 

antiseptics,  but  relies  upon  clean  water  at  first,  and  a  dry  blood  clot  after- 
ward. 

The  little  favor  which  tursectomy  had  secured  at  the  time  of  writing 
the  article  on  orthopedic  surgery  by  Frederick  R.  Fisher  (of  the  London 
Victory  Hospital  for  Sick  Children)  in  the  6th  volume  of  Ashurst's  En- 
cyclopedia of  Surgery,  1886,  is  shown  by  the  remark  that  "the  num- 
ber of  cases  of  club  foot  treated  by  excision  of  the  tarsus  may  be  num- 
bered by  tens,  while  the  cases  treated  by  the  ordinary  methods  may 
be  numbered  by  thousands." 

There  is  not  anywhere  on  the  limbs  a  more  dangerous  place  for  the 
invasion  of  putrefactive  agents  than  the  joints  of  the  tarsal  bones. 

The  joints  of  the  carpus  are  equally  complicated,  but  they  are  not  so 
often  a  field  for  those  surgical  processes  which  expose  them  to  the  air. 
There  is  a  labyrinth  impossible  to  explore  completely  with  antiseptic 
means  for  hunting  out  septic  agents.  The  most  effective  searcher  is  per- 
oxyde  of  hydrogen,  but  there  are  blind  pockets,  which  easily  resist  the 
pressure  of  the  oxygen  eliminated  by  the  contact  of  pus.  The  septic 
fluids  are  squeezed  into  corners,  to  expand  again  and  renew  their  de- 
structive war  on  the  living  tissues. 

The  exsection  of  portions  of  the  tarsus  for  the  relief  of  deformities 
of  the  feet  requires,  for  the  most  successful  results,  that  the  after  dress- 
ings be  exclusively  wet  or  exclusively  dry. 

The  dry  dressing  is  most  convenient,  requiring  no  attention  for  days. 

The  blood  serum  becomes  squeezed  out  of  the  clot;  absorbed  by  the 
dressings,  and  the  residual  clot  becomes  penetrated  by  the  proliferating 
vessels  until  it  is  entirely  replaced  by  new  tissue. 

When  this  process  of  the  invasion  of  the  clots  by  the  blood  cells  and 
blood  vessels  emanating  from  the  adjoining  tissues  is  complete:  the 
danger  of  infection  bycontact  with  the  air  is  nearly  passed. 

The  contact  of  the  germs  of  erysipelas,  phlegmon,  and  of  gangrene 
may  set  up  destructive  changes,  but  with  moderate  washing  the  pus  cov- 
ering the  granulating  surfaces  will  remain  laudable  and  cicatrization  will 
go  on  rapidly. 

For  the  dry  dressing  to  succeed,  it  is  necessary  that  the  implantation 
of  germs  at  the  time  of  operation  be  avoided,  or  that  they  be  sterilized 
by  the  washes  applied  to  the  wound  previously  to  the  application  of  the 
dressings.  In  this  relation,  the  character  of  the  blood  clot  is  of  some 
importance.  It  is  desirable  that  its  solidity  be  not  diminished  by  the 
application  of  water.  A  squeezed  sponge  does  not  impart  any  water  to 
the  surfaces  to  which  it  is  applied,  but  it  drinks  up  any  fluid  that  may  be 
there,  leaving  dryer  than  before  such  clot  as  may  remain. 

Mr.  Richard  Davey  of  the  Westminster  Hospital,  London,  was  in  1884  a 
a  disbeliever  in  the  ideas  now  generally  accepted  with  regard  to  antisep- 
tics. In  an  operation  by  him  for  talipes  varus  upon  a  12-year-old  boy,  wit- 
nessed by  the  writer  in  1884,  he  removed  a  wedge-shaped  portion  of  the 
tarsus  by  a  saw  working  in  the  groove  of  a  director  passed  over  the 
bones  and  under  the  soft  tissues  of  the  top  of  the  foot.  The  wound  was 
dressed  in  its  own  blood  without  the  application  of  water  and  a  splint 
applied  to  prevent  motion. 


20 

The  notion  of  the  excellence  of  blood  as  a  wound  dressing  is  an  old 
popular  tradition,  and  there  is  some  truth  in  it,  but  the  exposure  to  the 
air  of  non-putrefaction  dressing  impervious  to  floating  atmospheric  dusi 
must  be  far  superior  to  the  surface  of  a  blood  clot  with  its  aon-sterilized 

retaining  bandage.  The  surface  of  clot  thus  exposed,  invariably  becomes 
putrid  in  this  climate,  and  in  dryness  London  can  have  no  superiority  over 
us.  That  a  dressing  of  undiluted  blood  may  be  better  than  non-sterilized 
dressings  may  readily  be  conceived,  but  in  this  day  it  is  a  queer  freak  to 
scoff  at  antiseptic  agents  and  rely  upon  such  a  perishable  defense  against 
atmospheric  putrefaction  as  blood.  It  is  true,  blood  is  a  natural  dress- 
ing, but  the  instinct  of  the  dog  leads  him  to  lick  it  off. 

The  wet  dressing,  the  lotion  being  carbolized  or  sublimated  water,  is 
sure,  but  more  troublesome.  In  this  plan  of  management  the  omission 
of  fresh  application  of  carbolic  acid  for  some  hours  is  disastrous.  The 
agents  of  decomposition  pass  readily  through  the  damp  dressings  to  the 
wound  and  to  its  fluid  or  its  solid  or  semi-solid  contents. 

The  discontinuance  of  a  sublimate  wash  after  beginning  on  the  wet 
plan,  leaving  the  dressings  to  become  partially  dry,  is  less  dangerous. 

The  mercurial  does  not  go  off  into  the  air  like  carbolic  acid,  but  it 
may  be  absorbed,  or  by  dryness  become  inactive  along  the  surfaces  sur- 
rounding a  wound,  permitting  the  microbes  of  decomposition  to  pass  in 
Constantly  wet  or  constantly  dry,  should  therefore  be  the  maxim. 

If,  before  the  dressing  is  applied,  the  wound  has  become  infected 
with  germs  beyond  the  power  of  the  exudates  to  digest  and  destroy 
them,  the  dry  method  must  be  a  failure.  Only  the  frequent  or  perpetual 
drip,  or  the  bath,  can  insure  against  suppuration  and  putrefactive  com- 
plications. 

In  the  case  of  long  exposure  to  the  air,  as  in  accidental  wrounds,  the 
wet  dressing  should  be  employed  so  as  to  secure  the  perpetual  presence 
of  the  antiseptic  until  the  time  when  the  exudates  upon  the  surfaces  of 
the  wound  have  become  replaced  by  organized  material.  After  that,  the 
more  convenient  form  of  dry  dressing  may  be  employed  with  safety,  the 
purulent  product  being  carefully  wrashed  away  sufficiently  often. 

From  these  considerations,  the  application  of  a  dressing  perpetually 
wet  with  an  antiseptic  lotion  must  be  the  safest  for  wounds  exposed  a 
considerable  time  to  the  air,  and  especially  to  gun  shot  wounds  present- 
ing irregular  and  ragged  surfaces,  some  of  which  are  likely  to  be  ne- 
crosed, though  under  a  careful  antiseptic  drip  or  bath  they  need  never 
present  any  smell  or  other  sign  of  gangrene.  This  is  a  distinction  im- 
portant to  secure.  The  necrosed  tissues  following  a  gunshot  injury  or  a 
telipes  operation,  behaves  like  catgut  ligatures.  They  are  absorbed  if 
not  too  large  or  too  resisting  for  the  digestive  powers  of  the  lecucosytes, 
or  they  remain  for  a  gradual  odorless  maceration  or  final  expulsion.  If 
exposed  to  the  action  of  suppuration  and  putrefaction  germs  they  mor- 
tify and  smell. 

MANNER  OF  OPERATING. 

For  cases  in  which,  on  account  of  age  or  the  degree  an  ,  resistance  of 
the  deformity,  it  is  necessary  to  remove  a  portion  of  the  tr.rcal  bones,  the 
following  method  is  recommended: 


21 

Richard  Davey,  of  the  Westminster  hospital,  says  that  he  tried  chisels 
but  abandoned  them  for  the  saw. 

The  writer  tried  the  saw  and  abandoned  it  for  chisels. 

Only  one  opening  of  the  skin  is  necessary,  and  four  instruments  are 
enough — a  knife,  two  chisels  and  a  mallet. 

After  an  antiseptic  washing  of  the  skin  and  the  cleaning  out  of  any 
residual  material  between  the  toes  and  among  the  folds  of  the  deformed 
foot,  an  incision  is  made  along  the  outer  side  of  the  foot. 

Figs.  9  and  10  illustrate  the  form  of  the  foot  and  the  necessary  place  of 
the  incision.    The  dotted  lines  indicate  the  course  of  the  chisel. 


Fig.  9.  Fi&.  10. 

Fig.  10,  left  foot.  The  dark  line  indicates  the  incision  and  the  dotted 
lines,  the  passage  of  the  chisels  through  the  bones;  when  the  chisels 
come  into,  contact  each  helps  the  other  to  pry  out  the  included  portion  of 
the  tarsus. 

In  Talipes  varus,  including  nine-tenths  of  the  whole  number  of  foot 
deformities,  the  incision  is  made  along  the  outer  edge  of  the  foot  from 
the  proximal  end  of  the  metatarsal  bone  of  the  little  toe,  to  the  cuboid 
bone  or,  in  extreme  cases,  to  the  calcaneum,  as  the  intention  may  be  to 
make  a  larger  or  smaller  amount  of  excavation.  These  two  chisels  come 
into  contact  on  the  inner  or  medium  side  of  the  foot,  and  each  serves  as 
a  lever  to  lift  out  the  portion  of  the  tarsus  included  between  the  two 
chisels.  This  is  the  principle  of  the  proceeding,  though  in  practice,  the 
bones  and  ligaments  may  require  to  be  removed  in  smaller  pieces  than  this 
description  implies.  The  exact  amount  of  excavation  is  determined  by 
the  extent  necessary  to  restore  the  correct  form  of  the  foot  by  the 
hands  of  the  operator  at  the  time. 

If  the  case  is  one  of  Talipes  varus,  there  is  no  advantage  in  dividing  the 
heel  tendon,  but  if  the  equinus  element  is  strong  (Talipes  equino-varus), 
there  is  great  advantage  in  dividing  this  tendon,  as  the  first  step  in  the 
operation.     In  this  case  the  tendon  is  put  upon  the  stretch  and  the  bistoury 


22 

introduced  on  the  median  side.  No  stitches  are  taken  in  the  foot  because 
the  surfaces  arc  lcl'1  in  the  most  raided  condition  possible:  Fags  of  bone, 
joint  cartilage,  ligamenl  and  connective  tissue  become  surrounded  by  blood 
clot.  These  loose  ends  are,  most  of  them,  in  a  condition  to  slough  if  left 
to  their  own  power  of  maintaining  their  circulation.  Any  plan  which 
fails  to  maintain  the  vital  capability  of  the  blood  clot  must  be  a  failure. 
Many  of  these  fragments  of  tissue  lie  in  the  clot  to  be  afterward  per- 
petuated in  their  vitality  by  the  approach  and  penetration  of  the  capil- 
laries extending  themselves  through  the  clot  from  the  adjacent  surfaces, 
which  have  been  left  in  such  relations  as  to  maintain  their  full  vitality. 

(1.)  Before  the  removal  of  the  elastic  bandage,  which  had  been  ap- 
plied to  the  limb  above  in  order  to  secure  a  bloodless  operation,  the  dry 
wound  is  washed  with  a  warm  sublimate  solution,  1-1000.  Then  (2d) 
sublimated  lint  is  applied  over  the  wound  and  the  foot  is  brought  into 
the  best  approximation  to  the  correct  form,  and  retained  by  adhesive 
plasters  extending  from  the  outer  surface  of  the  foot  to  the  upper  part  of 
the  leg.  A  sufficient  amount  of  sublimated  absorbing  material  is  then 
applied  to  drink  rip  the  blood  and  serum  subsequently  escaping.  (3d.) 
A  gypsum  plaster  is  then  applied  in  order  that  the  patient,  on  waking 
from  his  narcosis,  may  throw  his  foot  about  without  hurting  it.  After 
this  is  clone  (4th)  the  elastic  bandage  is  taken  off  the  leg,  permitting  the 
wound  to  fill  with  blood  and  the  serum  to  escape  into  the  surrounding 
absorbent  material. 

By  this  procedure,  the  blood  escapes  dilution  by  water,  and  its  clot 
is  the  most  solid  possible,  free  from  the  possibility  of  septic  infection, 
and  best  adapted  to  the  preservation  of  its  blood  cells  and  to  their  subse- 
quent restoration,  and  also  to  the  penetration  from  the  surrounding  living 
parts,  of  leucocytes  and  proliferating  blood  vessels. 

The  rule  is  to  leave  this  dressing  untouched  for  a  week  or  more,  till 
there  ordinarily  comes  some  smell.  By  this  time,  the  blood  clot  will 
have  become  alive  again  with  some  power  of  resistance  to  the  encroach- 
ment of  enemies.  Afterward,  elastic  extension  is  kept  up  until  the  short 
ligamentous  connections  about  the  ankle  joint  have  adjusted  themselves 
under  the  influence  of  this  perpetual  tension.  (See  fig.  2  and  explana- 
tions.) It  afterwards  becomes  necessary  to  wear  a  brace  for  a  long  time 
in  order  to  retain  what  has  been  attained,  whether  the  treatment  has  been 
executed  with  or  without  cutting.     (See  figures  2,  3  and  8). 

Nothing  is  more  common  than  the  loss  of  some  of  the  success  of 
treatment  by  neglect  after  the  cessation  of  treatment.  To  avoid  this  loss, 
it,  is  important  that  the  deformity  be  over  corrected  before  the  active 
treatment  is  discontinued. 

In  case  of  Talipes  equinus,  or  Talipes  equino-varus,  the  improve- 
ment under  treatment  should  be  carried  so  far  that  the  natural  use  of  the 
foot  will  tend  to  preserve  the  advantage  that  has  been  gained.  It  is  never 
safe  to  dismiss  a  case  as  cured  until  this  degree  of  success  has  been 
attained. 

The  manner  of  dressing  should  be  further  explained:  Gypsum  is 
never  employed  except  temporarily  after  some  operation,  with  or  without 
cutting,  in  order  to  shield  the  part  from  the  pain  attendant  upon  move- 
ment or  to  hold,  for  brief  periods,  some  position  forced  upon  it  under 
narcosis,  hy  pressure  of  the  hands.  In  the  latter  case,  a  screw  clam])  or 
an  elastic  bandage  over  and  around  a  splint  is  resorted  to  until  after 
the  hardening  of  the  gypsum.  An  elastic  tension  for  changing  the  form 
should  not  be  employed  until  the  soreness  immediately  following  an 
operation,  by  cutting  or  by  force,  has  passed  by. 


To  retain  form  and  to  prevent  pain  are  the  functions  of  plaster. 

To  improve  form  is  the  function  of  elastic  tension,  and  it  is  made 
elastic  in  order  that  some  imitation  of  the  natural  movements  may  he 
permitted,  thus  securing  an  active  circulation  and  a  rapid  change  of  nu- 
trition through  which  short  ligaments  become  elongated  and  those  too 
long  become  shortened.  The  discomfort  of  a  perpetual  position  is  re- 
lieved by  a  little  movement.  If  by  any  imperfection  or  mistake  in  man- 
agement, the  wound  becomes  putrefactive  the  perpetually  wet  dressing 
must  be  resorted  to  and  kept  up  until  all  odor  hasTfor  a  considerable 
time  ceased  to  be  produced. 

The  detail  of  this  proceeding  is  very  important.  The  affected  foot 
should  be  immersed  for  a  considerable  time  in  a  warm  bath,  having 
1-1000  Hg.  C12  . 

The  wounds  and  its  sinuses  should  be  injected  with  this  solution 
diluted  one-half  by  peroxyde  of  hydrogen.  Afterward  the  foot  is  to  be 
enveloped  in  a  dressing  kept  perpetually  wet  with  a  1  per  cent  .solution 
of  carbolic  acid. 

If  the  invasion  of  putrefactive  enemies  is  not  promptly  repelled  by 
antiseptic  measures  the  result  may  be  disastrous.  The  wound  made  in 
the  exsection  of  the  tarsus  unavoidable  exposes  the  tendons  of  the 
Flex,  long  policis,  flex  long  digitorum  tibialis  anticus  ext.  longus  digi- 
torum  and  peroneous  tertius  which  pass  up  the  leg  and  afford  a  ready 
passage  for  the  fire  of  septic  inflammation.  If  the  life  of  the  patient  is 
saved,  yet  great  loss  of  time  is  experienced  in  the  course  of  the  treat- 
ment. 

INTBRNAL  INCISION. 

"  OPEN  INCISION  AND  FIXED  EXTENSION." 

"  In  the  transactions  of  the  International  Medical  Congress  meeting 
in  Copenhagen  in  August,  1884,  is  a  contribution  by  Dr.  A.  M.  Phelps,  of 
Chateaugay,  N.  Y.,  advocating  the  treatment  of  obstinate  Talipes  varus  by 
an  open  incision  on  the  inner  side  of  the  foot. 

In  the  Medical  News  (Philadelphia)  for  January  21st,  1888,  this  opera- 
tion is  explained  and  illustrated  by  a  wood  cut  by  Dr.  C.  N.  Dixon  Jones, 
of  Brooklyn,  N.  Y. 

The  lines  of  the  incision  are  seen  upon  the  right  foot  in  Fig.  10. 

An  incision  is  made  from  the  internal  malleolus  to  the  tuberosity  of 
scaphoid,  and  from  the  center  of  this  line,  another  incision  is  made  verti- 
cally downward,  dividing  everything  that  resists,  until  by  forcible  pres- 
sure, the  foot  can  be  straightened  out. 

The  artery  and  the  nerve  are  drawn  aside  and  held  by  a  blunt  hook  as 
the  dissection  goes  on.  The  foot  is  held  in  its  corrected  position  by  gyp- 
sum four  weeks  before  the  first  dressing  is  removed. 

The  dissection  of  the  inner  side  of  the  foot  is  favorably  referred  to  in 
the  "  Year  Book  "  for  1887  by  Dr.  Philippson  (Deutsch  Zeits.,  f .  Chirurg, 
XXV.  287,  for  1886-7.  Dr.  Gibney  (Trans.  Med.  Soc.  State  of  N.  Y., 
1886),  p.  368,  refers  favorably  to  the  Phelps  method  and  states  that  Dr. 
Bradford,  of  Boston,  has  been  working  at  a  machine  which  he  calls  a 
Tarsoclast. 

In  the  progress  of  treatment,  with  or  without  the  division  of  bones 
and  tissues,  it  is  convenient  to  employ  not  only  the  force  of  the  hand, 
but  alsD  the  force  of  a  screw  in  some  form  of  apparatus  in  which  a  car- 
penter's screw  clamp  constitutes  the  force  which  is  to  change  the  form  of 
the  foot. 

Apparatus  other  than  that  which  can  be  extemporized  at  any  time  has 
been  worked  at  by  Monier,  as  reported  in  the  "  Year  Book,"  1887,  from 
Gazette  des  Hoperaux  No.  1,  January,  1887. 

It  is  doubtful,  however,  whether  a  permanent  apparatus  can  be  made 
to  do  any  better  than  an  extemporized  carpenter's  clamp  and  two  pieces 
of  wood  and  three  roller  bandages. 


st.  i.ouis  Medical  and  Surgical  Journal,  Pebrnary,  ivv'. 


A  RECTAL  OBTURATOR, 


The  basis  of  the  following  communication  was  presented  to  the  St. 
Louis  Medical  Society.  Nov.  18th.  1882,  exhibiting  a  rectal  stopper  or 
obdurator. 

1.  For  enabling  the  alimentary  canal  to  hold  two  or  three  gallons  of 

water  in  cases  of  obstinate  constipation,  in  cases  of  obstipation  and  of 
strangulation:  or.  for  the  speedy  and  complete  washing  out  of  the  ali- 
mentary canal  on  any  account. 

'2.  For  the  holding  in  the  alimentary  canal  of  comparatively  large 
amounts  of  nutritious  fluids  in  cases  in  which  the  introduction  of  food 
by  the  mouth  is  impracticable. 


ANAL  OR  RECTAL  OBTURATOR  OR  STOPPER  IK  POSITION  UPON  A  WALES'  BOUGIE. 

3.  For  the  holding  in  the  large  intestine  of  an  adequate  quantity  of 
alcoholic  liquids  introduced  for  anesthesia  in  surgical  operations,  or  in- 
juries, or  for  the  alleviation  of  shock  or  terror  from  any  cause  or  in  all 
conditions  in  which  alcoholic  anesthesia  is  desirable. 

4.  For  the  speedy  dilution  of  the  blood  through  the  absorption  of 
water  from  the  intestinal  surfaces  in  order  to  stimulate  the  kidneys  to 
filter  out  any  poisonous  constituents  of  the  blood,  whether  these  impuri- 
ties have  been  introduced  by  accident  or  design,  or  whether  they  have 
developed  in  the  blood  and  in  the  glands  by  the  chemical  process  inci- 
dent to  disease. 

5.  For  the  reduction  of  temperature  in  lever  and  inflammation  by  the 
more  ready  discharge,  through  the  various  emunctories,  of  irritating  ma- 
terial by  the  thinning  of  the  blood  through  the  introduction  of  water. 

6.  For  the  raising  of  the  peritoneal  floors  of  the  pelvis,  in  order  to 
increase  the  facility  in  the  removal  of  adherent  ovaries,  tubes  or  tumors. 
approached  from  above  by  laparotomy. 

I  have  taken  great  interest  in  the  efforts  of  Dr.  Wales,  late  Surgeon- 
General  of  the  United  States  Navy,  to  construct  a  bougie  by  which  the 
large  intestine  can  be  well  distended  in  cases  of  intestinal   obstruction; 


and  in  some  cases  of  obstruction  I  have  been  unexpectedly  successful  iii 
securing  a  movement  of  the  bowels  by  an  introduction  of  the  bougie 
high  up.  This  is  a  specimen  of  AVales'  bougie  (showing  the  bougie); 
but  manage  it  as  you  may,  the  water  is  likely  to  leak  out  and  the  full  ex- 
tent of  the  desirable  result  may  not  be  obtained.  Reflecting  upon  this 
subject,  it  seemed  to  me  that  if  there  were  an  obturator  fitting  inside  the 
sphincter,  it  would  effectually  prevent  the  regurgitation  of  the  water 
used,  so  that  the  large  intestine  would  be  completely  filled  and  passing 
the  ilio-coecal  valve,  filling  the  small  intestine  also,  I  wrote  to  Mr.  Stohl- 
mann,  of  Tiemann  &  Co.,  telling  him  what  I  wanted,  and  a  few  days 
ago  I  received  this.  This  is  to  be  filled  with  air  or  water  (referring  to 
the  obturator),  and  is  intended  to  be  of  such  a  size  as  to  fill  the  lower 
part  of  the  anus  and  act  as  a  valve,  so  that  the  greater  the  pressure  is 
above,  the  tighter  it  will  fit.  In  using  this,  according  to  this  idea,  it 
should  be  placed  upon  the  bougie  previous  to  its  introduction.  The 
bougie  is  then  worked  up  as  far  as  convenient  and  the  obturator  pushed 
in  through  the  sphincter,  and  after  being  inside  the  sphincter  it  should 
be  injected  with  water  or  blown  up  with  air.  It  is  probably  better  to  use 
water  because  it  is  not  so  likely  to  leak  away  as  air;  you  then  fasten  to 
the  tube  some  kind  of  syringe  and  fill  the  large  intestine.  The  practi- 
cability of  securing  a  disentanglement  of  a  strangulated  intestine,  the  ob- 
struction being  occasioned  by  a  loop  of  intestine  caught  upon  a  bridge, 
which  may  be  the  result  of  a  previous  inflammation,  or  occasioned  by  in- 
tussusception, in  which  the  upper  portion  of  the  intestine  is  drawn  into 
the  lower — the  practicability  of  this  has  been  established  by  many  suc- 
cesses. Where  the  obstruction  is  below  the  ileo-coecal  valve,  there  can 
be  no  doubt  of  the  ability,  with  the  obturator,  to  fiil  the  large  intestine 
below  the  obstruction  and  exert  an  influence  to  disentangle  it,  It  is  not 
to  be  supdosed  that  all  the  attempts  will  be  successful,  for  ihere  may  be 
such  adhesions  as  to  make  it  impracticable,  as  in  the  case  of  strangula- 
tion, in  hernia  in  the  inguinal  canal,  or  under  the  femoral  arch.  The 
expedient  might  be  supposed  to  fail  in  cases  of  strangulation  of  the  small 
intestine,  on  account  oj  the  tight  fitting  of  the  ileo-coecal  valve,  but  the 
experiments  made  by  Dr.  Thomas  Battey  upon  the  dead  subject,  prove 
that  the  ileo-coecal  valve  yields  when  the  pressure  becomes  more  than 
moderate. 

Water  passed  into  the  small  intestines  in  three  cases  out  of  four  ex- 
periments by  the  writer  upon  the  dead  subject.  In  this  fourth  case  the 
valve  was  tight,  resisting  pressure  sufficient  to  burst  the  colon. 

Since  the  first  publication  in  1883,  the  apparatus  has  been  improved 
by  Tiemann  &  Co.;  and  further  use  has  established  its  value. 

Within  a  few  days,  (March,  1888,)  four  days  after  the  removal  of  an 
ovarian  tumor,  there  was  a  failure  to  secure  a  movement  of  the  bowels 
by  liberal  dosing  with  elaterium  and  croton  oil.  In  a  brief  period  after 
the  employmentTof  the  obturator  and  the  distension  of  the  large  intestine, 
there  came  a  fecal  evacuation.  The  danger  in  such  a  case  is,  that  the 
natural  force  of  the  muscular  vermicular  contraction  of  the  intestine, 
forcing  gas  and  liquid  down  upon  the  part  held  by  a  recent  adhesion, 
may  not  be  sufficient  to  straighten  out  the  kink  which  stops  the  progress 
of  the  intestinal  contents. 

A  distension  from  the  filling  of  the  large  intestine  below,  may  bring 
the  strictured  portion  into  such  a  position  that  the  contracting  forces  may 
straighten  the  small  intestine  and  enable  the  vermicular  force  to  tear  the 
exudate  which  was  causing  the  arrest. 


PALATOPLASTY. 


A  paper  explaining  new  instruments  and  new  methods  of  operating 
for  Cleft  of  the  Palate,  was  read  before  the  St.  Louis  Medical  Society, 
November  28,  1874,  published  in  the  "St.  Louis  Medical  and  Surgical 
Journal,"  January,  1875;  copied  with  cuts  in  the  "London  Medical 
Record,"  March  3,  1875,  and  revised  and  published  with  additions  in  the 
"  American  Practitioner,"  for  March,  1876.  A  report  was  also  made  to 
the  Illinois  State  Medical  Society,  in  May,  1884,  and  to  the  International 
Medical  Congress,  meeting  in  Copenhagen,  in  August,  1884. 

Since  the  time  of  the  first  presentation,  the  methods  have  been  im- 
proved, and  a  new  instrument  devised.  A  new  modification  of  the 
quilled  suture  has  been  introduced,  which  will  be  described  under  the 
name  of  the  Bead  Suture. 

The  employment  of  the  new  methods  and  instruments,  is  found  very 
much  to  shorten  the  duration,  while  the  loss  of  substance  is  lessened,  and 
the  probability  of  union  by  the  first  intention  is  increased. 

The  facility  with  which  the  two  halves  of  the  cleft  palate  may  be 
united  is  not  generally  understood.  There  is  an  equal  want  of  apprecia- 
ion  of  the  advantage  of  an  early  operation,  made  before  the  expiration 
of  the  imitative  period  of  life.  For  illustration:  the  reason  why  adult 
persons  fail  to  learn  to  pronounce  accurately,  the  peculiar  sounds  of  a 
foreign  language,  is  not  in  the  constitution  of  the  organs  of  speech,  but 
in  the  inability  to  adapt  muscular  action  to  new  results.  The  child  varies 
muscular  movements  until  the  exact  sound  is  secured,  and  ever  after, 
ward,  the  muscles  move  so  as  to  secure  the  same  sound.  The  difficulty 
experienced  in  learning  a  foreign  language,  applies  more  emphatically, 
in  the  case  of  cleft  palate.  The  muscular  deficiency  may  be  completely 
removed,  but  the  lack  of  muscular  education,  hinders  the  acquisition  of 
perfect  speech.  One  of  the  difficulties  in  self-education,  is  in  the  fact  that 
the  person  speaking  does  not  know  that  his  pronunciation  is  wrong.  It 
is  often  noticed,  for  example,  that  a  child  which  has  acquired  some  pecu- 
liarity in  speaking,  does  not  notice  that  its  pronunciation  is  peculiar  and 
it  is  with  the  greatest  difficulty  that  the  habit  can  lie  overcome.  This 
difficulty  inheres  in  the  habit  of  false  pronunciation. 

The  same  force  of  habit  continues,  alter  an  operation  for  the  closure 


27 

of  a  cleft  palate.  By  careful  drill,  the  defects  of  pronunciation  can  be 
overcome,  little  by  little,  until  the  detail  of  speech  becomes  nearly  or 
quite  perfect.  It  is  probable,  that  much  of  the  depreciation  in  which  the 
operation  is  held,  is  owing  to  this  want  of  drill,  after  an  operation  which 
is  in  itself  perfect. 

It  follows  from  this,  that  the  work  is  only  half  done  when  the  closure 
of  the  palate  is  secured,  even  in  the  most  perfect  manner.  Many  persons 
will  learn  to  execute  the  proper  sounds  when  speaking  slowly,  and  yet, 
in  ordinary  rapid  conversation,  they  will  speak  as  badly  as  before.  The 
only  remedy  for  this  habit,  is  to  forbid  ordinary  conversation,  for  a  time, 
and  to  permit  speaking  only  under  instruction,  every  mistake  being  cor- 
rected on  the  instant. 

At  the  meeting  of  the  Illinois  State  Medical  Society,  in  Chicago,  in 
May,  1884,  a  lad,  ten  years  old,  born  with  complete  cleft  of  the  palate, 
both  hard  and  soft,  was  presented,  who  read  in  a  clear  voice  so  as  to  be 
distinctly  heard  at  the  farther  end  of  the  room,  without  any  defect  or 
peculiarity  of  speech.  The  operation  had  been  made  in  two  sittings,  when 
five  years  old,  the  soft  palate  being  first  closed  and  the  hard  palate  sev- 
eral months  later. 

This  lad  has  not  only  recovered  perfect  speech,  but  he  can  whistle. 
This  implies  a  very  good  closure  of  the  palate  against  the  posterior  wall 
of  the  pharynx  ;  otherwise,  there  would  be  too  much  leak  of  air  through 
the  nostrils. 

The  ability  to  apply  the  palate  to  the  posterior  wall  of  the  pharynx  is 
greatly  aided  by  the  careful  drill  of  the  patient. 

The  backward  movement  of  the  palate  is  effected  by  the  palato- 
pharyngeus  muscle.  The  frequent  effort  induces  an  elongation  of  the 
muscular  fibres  and  a  consequent  expansion  of  the  muscular  curtain. 

The  patient  if  left  to  himself,  if  not  very  young,  might  never  make 
this  effort  and  never  be  educated  into  the  achievement  of  drawing  the 
palate  far  enough  back  to  close  the  posterior  communication  with  the 
nostrils. 

In  regard  to  the  operation  ;  in  the  progress  of  the  study  through 
several  years  it  was  found  that  the  division  of  the  pillars  of  the  fauces, 
practiced  by  Fergusson,*  is  worse  than  useless.  The  muscular  fibres  of 
the  anterior  pillars  approximate  the  two  halves  of  the  palate,  as  the 
genio-hyoglossus  protrudes  the  tongue.  The  division  of  these  muscles 
is  recommended  upon  the  the  false  theory  that  they  pull  the  two  halves 
of  the  palate  asunder,  The  palato-glossus  muscles  really  approximate 
the  two  halves. 

After  the  removal  of  a  strip  of  membrane  from  the  inner  edge  of  the  half 
palate  there  was  found,  in  practice,  to  be  a  tendency  in  the  anterior  mus- 
cular layer  to  glide  upon  the  posterior,  in  the  act  of  introducing  ordinary 
needles. 


*See*note  in  Gray's  Anatomy  in  connpction  with  a  description  of  the  palate  and  its 
connections. 


28 


To  prevent   this  occurence  the  needle  was 
constructed  which  is  shewn  in  fitnire  1. 


act    Shaft  and  handle. 
bb    Thread. 

c      Sliding  shaft  for  compressing  the  two  layers  of 
the  soft  palate  upon  the  point  of  the  needle. 
d      Point  of  the  needle. 


In  the  use  of  this  instrument  the  thread  is 
picked  up  by  a  tenaculum. 

Through  the  ingenuity  of  Dr.  G.  V.  Black, 
an  instrument  has  been  constructed  which 
picks  up  its  own  stitch,  thus  saving  much 
time. 

This  needle  is  in  two  forms. 


Figure  2  is  the  needle  working  direct: 

AA    Shaft  and  handle. 

Foot  piece  of   the  shaft  curved. 


Fig.  1. 


B  Foot  piece  of  the  shaft  curved.  Its  extreme 
point  has  an  orifice,  the  place  of  which  is  indicated  by  the 
dotted  line.  The  orifice  is  entered  by  the  needle  C  carry- 
ing the  thread  EE. 

C  Needle  with  thumb  piece  above  and  a  point  be- 
low: curved  so  that  the  point  will  pass  the  eye  indicated 
by  the  dotted  line. 

DD  Pick-up  pin  with  a  thumb  piece  above  its  sliding 
shaft,  and  its  fine  point  above  the  B.  As  the  shaft  (upper 
D)  goes  down,  the  pin  (lower  D)  moves  horizontally  and 
at  a  right  angle  to  its  shaft,  and  picks  up  the  thread  car- 
ried by  the  needle  C. 

EE  Thread  carried  by  the  needle  C,  and  picked  up  by 
the  stiletto  or  pin  indicated  by  D.  This  is  retained  while  the 
needle  is  withdrawn,  so  that,  on  displacing  the  shaft  AA, 
with  its  foot-piece  B,  the  thread  is  exposed,  and  can  be 
seized  by  a  tenaculum  or  by  the  fingers. 

The  point  of  exit  of  the  needle  corresponds 
with  that  of  its  entrance,  and  the  stitch  is  easily 
picked  up. 

It  is  convenient  to  introduce  into  the  first 
thread,  a  second  thread  looped  so  as  to  be 
doubled.  This  is  looped  into  the  thread  con- 
nected with  the  needle,  and  drawn  into  position, 
serving  to  introduce  the  silver  wire  with  which 
the  stitch  is  finally  completed. 

The  instrument  working  laterally  is  illus- 
trated in  figure  3. 


Fig.  3. 

aa    The  main  shaft  of  the  instrument  having  the  needle  upon  its  distal  end. 

66  The  movable  shaft,  a  thumb  piece  at  the  proximal  end,  and  an  orifice  at  the 
distal  end  to  enclose  the  needle  in  the  act  of  picking  up  the  thread 

c.c  The  pick-up  stiletto  which  picks  up  the  thread,  having  a  thumb  piece  at  the  prox- 
imal end  and  a  point  at  the  distal  end. 

d    The  curved  needle,   represented   as  having  pierced  the  tissue  intended  to  be 
sutured. 

ee  The  thread  with  which  the  needle  is  armed  and  which  has  been  picked  up  by  the 
pick-up  stiletto. 

The  pick-up  portion  of  the  instrument  is  in  the  position  in  which  it  is  about  to  be 
withdrawn  toward  the  handle,  so  as  to  bring  the  thread  within  reach  of  the  fingers  on  the 
outside,  when  the  instrument  is  employed  in  the  mouth  or  other  deep  place. 


Fig.  4.  Needle  acting  in  the  re- 
verse direction — the  needle,  which  is 
curved,  passing  behind  the  part  to  be 
stitched,  which  in  the  cut  is  repre- 
sented by  p. 


a  a  a  The  shaft  having  the  handle 
at  one  end  and  the  needle  at  the 
other. 


6  6b  Slide  carrying  the  pick-up 
stilletto,  which  in  the  cut  is  seen  to 
hold  fast  to  the  thread  c  which  it  is 
about  to  release. 


c  c  e  The  thread  which  has  been 
picked  up  after  passing  through  the 
tissue  p  to  tenaculum  holding  the 
thread  as  it  is  about  to  be  released  from 
the  grasp  of  the  pick-up. 


Fig.  4. 


30 

By  the  use  of  these  needles  the  time  necessary  for  the  operation  is 
greatly  diminished.  This  is  an  important  consideration  in  an  operation 
which  is  necessarily  slow. 

It  lias  until  now  been  a  desideratum  to  protect  the  shallow  sutures 
from  the  strain  occasioned  by  the  action  of  the  tenosor  palati  muscles; 
and  for  this  purpose,  Dieffenbach  many  years  ago  had  practiced  deep 
vertical  incisions.  The  dangerous  hemorrhage  occuring  in  some  instances, 
prevented  the  general  adoption  of  this  expedient. 

The  present  writer  has  employed  the  platinum  wire  heated  by  the 
galvanic  current  to  secure  a  vertical  parting  of  the  substance  without 
hemorrhage.  This  plan  is  found  to  be  attended  with  some  loss  of  sub- 
stance, and  is  on  that  account  objectionable. 

Since  that  time,  it  has  been  found  that  the  use  of  the  galvano-cautery 
can  be  discontinued  and  the  same  object  secured  without  waste  of  sub-, 
stance,  by  the  employment  of  a  modification  of  the  quilled  suture,  a  plan 
for  which  (with  cut)  may  be  found  in  the  Annals  of  Anatomy  and  Surgery 
for  March,  1883,  under  the  name  of  "The  Bead  Suture."  This  suture  is 
easy  of  introduction,  and  it  performs  the  office  of  a  splint — diminishing 
the  movements  of  the  parts  of  the  palate,  and  entirely  taking  the  strain 
off  from  the  shallow  stitches. 

The  necessity  for  wounding  any  of  the  deep  vessels  is  entirely  obviated, 
and  the  parts  are  held  so  firmly  together  that  failure  to  unite  by  the  first 
intention  must  be  a  rare  exception- 

The  cut  furnishes  three  illustra- 
tions of  the  bead  suture. 

1  The  completed  suture,  the  beads  ly- 
ing upon  the  natural  surface  of  the  skin        ;s?g 
or  mucous  membrane. 

2  At  the  bottom  is  the  same  stitch  in- 
complete. The  bite  of  the  forceps  em- 
ployed in  twisting  the  silver  wire  is  also 
seen. 

3  The  middle  figure  shows  the  em- 
ployment of  two  beads  on  a  side  for  greater 
breadth.  The  cut  also  shows  a  lateral  in- 
cision on  either  side  for  the  better  approxi-  I 
matron  without  tension.  The  beads  lie  in 
the  furrow  made  by  this  incision. 

The  suture  admits  of  tighten- 
ing up,  if  found  to  be  too  lax  at 
any  time  after  its  introduction. 

The  utility  of  the  closure  of  the 
cleft  palate,  both  hard  and  soft,  be- 
comes apparent  in  every  case. 
Sounds  which  are  impossible  with 
a  permanently  open  communica-  V 
tion  between  the  mouth  and  the  N 
pharynx,   and   especially    between  Pis.  14. 

the  mouth  and  nose,  become  executed  with  more  or  less  approximation  to 
perfection. 


31 

When  the  cleft  is  closed  by  operation  while  the  patient  is  young,  the 
result  is  better  than  when  closed  later,  simply  because  bad  habits  of 
articulation  are  less  fixed. 

It  will  be  readily  understood,  that  the  patient  with  cleft  palate  learns 
to  make  substitutions  for  the  true  sounds  by  the  movements  of  parts 
different  from  those  employed  in  natural  articulation, 

When  the  apparatus  of  articulation  is  restored,  the  patient  must  learn 
anew  how  to  use  it.  Unless  the  greatest  care  and  caution  are  observed, 
combined  with  instruction  in  minute  details,  the  restored  organs  will 
never  attain  a  performance  equal  to  their  capabilities. 

The  same  is  also  true  where  the  communication  is  closed  by  vulcanite 
obturators.  The  most  careful  drill  in  both  cases  is  necessary  in  order 
to  secure  the  best  results.  When  it  is  considered  how  difficult  it  is  to  cor- 
rect bad  habits  of  articulation  and  pronunciation  vdiere  the  organs  are 
perfect,  it  will  be  readily  admitted  that  the  patient  may  not  be  a  great 
credit  to  his  surgeon  if  left  to  talk  as  he  may,  without  having  some  one 
to  point  out  his  errors,  to  direct  him  how  to  correct  them,  and  to  insist, 
day  after  day,  on  the  best  use  by  the  patient  of  his  restored  articulating 
apparatus. 

M.  Trelat  relates  a  case  of  a  boy  with  cleft  palate  coming  from  Rouma- 
nia.  Before  leaving  Paris  he  had  learned  a  correct  pronunciation  of 
French  words,  but  he  still  retained  some  of  his  faulty  habits  of  pronun- 
ciation of  his  native  language.  He  had  his  bad  habits  to  correct,  while 
in  relation  to  the  language  which  was  new  to  him  he  had  no  habits  to 
correct. 

The  early  operation  results  in  an  approximation  of  the  two  sides  of 
the  face  through  the  approximating  power  of  the  muscles  acting  upon 
the  bones  of  the  face.  There  are  no  antagonizing  forces  tending  to 
spread  the  face  and  hence  a  small  force  acting  all  the  time,  produces  an 
appreciable  result.  As  the  face  is  narrowed  the  material  of  the  palate  is 
relatively  greater  and  more  capable  of  the  perfect  performance  of  its 
functions  and  thus  all  objections  are  to  some  extent  removed. 

Besides,  the  skillful  performance  of  the  operation,  occasions  very 
little  loss  of  substance. 


APHLST   BINDER     I 

;       Syracuse,  N.Y.  j 

Stockton,  Calif. 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsl.stx) 

RD91  P93  1888C.1 

An  aseptic  atmosphere,  club  toot;.  A  rect 


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